====== Spetzler Martin Grade 4 ======


Due to the complexity of [[Spetzler-Martin AVM grading system]] IV-V [[arteriovenous malformation]]s (AVMs), the management of these lesions remains controversial. 

====Case series====

Multicenter, retrospective cohort study to evaluate the outcomes after single-session stereotactic radiosurgery (SRS) for SM Grade IV-V AVMs and determine predictive factors. 

Patibandla et al. retrospectively pooled data from 233 patients (mean age 33 years) with SM Grade IV (94.4%) or V AVMs (5.6%) treated with single-session SRS at 8 participating centers in the [[International Gamma Knife Research Foundation]]. Pre-SRS embolization was performed in 71 AVMs (30.5%). The mean nidus volume, SRS margin dose, and follow-up duration were 9.7 cm3, 17.3 Gy, and 84.5 months, respectively. Statistical analyses were performed to identify factors associated with post-SRS outcomes. 

At a mean follow-up interval of 84.5 months, favorable outcome was defined as AVM obliteration, no post-SRS hemorrhage, and no permanently symptomatic radiation-induced changes (RIC) and was achieved in 26.2% of patients. The actuarial obliteration rates at 3, 7, 10, and 12 years were 15%, 34%, 37%, and 42%, respectively. The annual post-SRS hemorrhage rate was 3.0%. Symptomatic and permanent RIC occurred in 10.7% and 4% of the patients, respectively. Only larger AVM diameter (p = 0.04) was found to be an independent predictor of unfavorable outcome in the multivariate logistic regression analysis. The rate of favorable outcome was significantly lower for unruptured SM Grade IV-V AVMs compared with ruptured ones (p = 0.042). Prior embolization was a negative independent predictor of AVM obliteration (p = 0.024) and radiologically evident RIC (p = 0.05) in the respective multivariate analyses. 

In this multi-institutional study, single-session SRS had limited efficacy in the management of SM Grade IV-V AVMs. Favorable outcome was only achieved in a minority of unruptured SM Grade IV-V AVMs, which supports less frequent utilization of SRS for the management of these lesions. A volume-staged SRS approach for large AVMs represents an alternative approach for high-grade AVMs, but it requires further investigation
((Patibandla MR, Ding D, Kano H, Xu Z, Lee JYK, Mathieu D, Whitesell J, Pierce
JT, Huang PP, Kondziolka D, Feliciano C, Rodriguez-Mercado R, Almodovar L, Grills
IS, Silva D, Abbassy M, Missios S, Barnett GH, Lunsford LD, Sheehan JP.
Stereotactic radiosurgery for Spetzler-Martin Grade IV and V arteriovenous
malformations: an international multicenter study. J Neurosurg. 2017 Sep 8:1-10. 
doi: 10.3171/2017.3.JNS162635. [Epub ahead of print] PubMed PMID: 28885118.)).